Addressing the Connection Between Mental Health and Chronic Pain to - - PowerPoint PPT Presentation

Addressing the Connection Between Mental Health and Chronic Pain to Improve Patient Outcomes

June 17, 2020 Maddy Reinert, Mental Health America Monica Mallampalli, PhD, HealthyWomen Gretchen Clark Wartman, National Minority Quality Forum

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Chronic Pain and Mental Health: Findings from MHA Screening

Maddy Reinert, Mental Health America

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The results help us understand people who are struggling

Screeners are in Pain

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1% 3% 8% 12% 12% 31%

0% 5% 10% 15% 20% 25% 30% 35%

Cancer Movement Disorders Heart Disease Diabetes COPD or other lung conditions Arthritis or other chronic pain

Check Multiple N= 578,846

Screeners with Pain More Likely to be White, Female and Older

• Less diverse than the

general population (75% White)

• 76% identified as Female
• 60% of screeners 65+

report chronic pain

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75%

Race/Ethnicity

Asian or Pacific Islander Black or African American (non- Hispanic) Hispanic or Latino More than one of the above Native American or American Indian Other White (non-Hispanic)

People Reporting Chronic Pain More Likely to Screen Positive for a Mental Illness

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79% 21%

N=161,363

Positive or Moderate to Severe Negative or Minimal to Mild

People with Chronic Pain are Most Likely to Screen for PTSD

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20% 30% 33% 33% 37% 38% 48%

0% 10% 20% 30% 40% 50% 60%

Youth Eating Disorder Psychosis Depression Anxiety Bipolar PTSD

Lack of Mental Health Treatment and Supports

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34% 66%

Ever Received Mental Health Treatment or Support?

No Yes

40% 60%

Ever Been Diagnosed with a Mental Health Condition?

No Yes

Most Concerned about Past Trauma and Loneliness

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Reason

Number of Responses Percent of Respondents

Past Trauma 5,824 61% Loneliness or Isolation 5,644 60% Relationship Problems 3,947 42% Grief or loss of someone or something 3,523 37% Financial Problems 3,426 36% COVID-19 3,232 34% Current events (news, media, etc.) 2,568 27%

N=9,479 4/13-5/31 scoring moderate to severe, “Choose up to 3”

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“Severe dysfunctionality, extreme difficulty taking care of myself day-to-day and week- to-week, including ADL's & making even the most very basic of everyday decisions to the point of immobilization/virtual paralysis” “Unable to take care of myself

• r my household duties”

“Constant pain, no hope for future” “Worrying about my family's health, the kind of chronic disease, and trying to make sure that everyone is OK and well.” “Not being able to exercise in a safe way to let off steam” “Hurting all the time”

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So What Can We Do?

• Expand resources for team-based care, with

behavioral health as a central feature.

• Focus on trauma and psychological supports.
• Invest in better treatment, and translate new

evidence into shared decision-making tools.

Facebook.com/mentalhealthamerica Twitter.com/mentalhealtham Youtube.com/mentalhealthamerica

Contact Us

Mental Health America 500 Montgomery Street Suite 820 Alexandria, VA 22314

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Maddy Reinert mreinert@mhanational.org

Chronic Pain & Mental Health Connection in Women

Monica Mallampalli, PhD Senior Advisor, Strategic & Scientific Initiatives Healthy Women

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Mission & Values

MISSION Educate women ages 35 to 64 to make informed health choices. VALUES

Trusted Partner: We educate and engage women by providing them with scientifically- reviewed, evidence-based information that allows them to make informed health choices to live well and age well. Independent Voice: Our reputational value to our stakeholders is in serving as the leading source of women’s health information, which we execute on through transparency in all relationships and collaborations. Digital Excellence: Every day, we work to serve women by providing access to timely, inspiring and enduring online content. Thought Leadership: Our ability to grow, innovate and shape the future of women’s health is in our ability to identify and set the agenda around topics before they become critical and to share our knowledge with stakeholders.

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Chronic Pain and Mental Health Prevalence

Both common with high prevalence in the general population

• Chronic pain is associated with a greater risk of

developing or having mental health disorders (panic disorder, generalized anxiety disorder, depression).1

• 35-45% of chronic pain patients experience

depression.2

• 75% of patients with depression also report pain.2
• 1. Means-Christensen, A.J. et al. (2008). Relationships among pain, anxiety, and depression in primary care.

Depression and Anxiety, 25(7), 593–600.

• 2. Vadivelu, N, Kai, AM. et al. (2017). Pain and Psychology-A Reciprocal Relationship. Ochsner J. Summer;

17(2): 173–180.

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Chronic Pain Facts

• 1. Dahlhamer J, et al. (2018). Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults, United
• States. MMWR. 2018;67(36):1001-1006.
• 2. Bartley EJ, and Fillingim, RB. (2011). Sex differences in pain: a brief review of clinical and experimental findings. Br J
• Anaesth. Jul; 111(1): 52–58.
• 3. Avis NE, et al. (2003). Health-related Quality of Life in a Multiethnic Sample of Middle-Aged Women: Study of

Women's Health Across the Nation (SWAN). Med Care. Nov;41(11):1262-76.

• 4. Institute of Medicine, Relieving Pain in America, 2011

50 million in the U.S. suffer from chronic pain1 Women frequently report pain than men2 Estimated 1:3 women impacted by chronic pain1 Racial/ethnic differences exist in chronic pain3 Annual economic cost of chronic pain is $635B4

Chronic Pain & Mental Health Connection

• Bidirectional relationship in

part due to shared underlying neural mechanisms

• Understanding their precise

relationship can predict better response to chronic pain treatment and management for patients.

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Chronic Back Pain Depression

3x 6x

Migraine Anxiety

2x 2-3x

CHRONIC PAIN CONDITIONS MENTAL HEALTH DISORDERS

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COVID-19 Impact on Chronic Pain & Mental Health

• Anxiety, depression and PTSD higher in women and

in individuals with chronic co-morbid conditions.1, 2

• Social distancing along with depression and anxiety

are exacerbating the expression and perception of pain further.2

• Immunocompromised patients are at greater risk

for COVID-19 infection.3

86%

Experiencing increased stress

64%

Experiencing increased pain as a result of COVID-19

• 1. Frederiksen B, Gomez I, Salganicoff A and Ranji U. Coronavirus: A Look at Gender

Differences in Awareness and Actions. Kaiser Family Foundation. March 2020.

• 2. Özdin S, Özdin SB. (2020). Levels and Predictors of Anxiety, Depression and Health

Anxiety During COVID-19 Pandemic in Turkish Society: The Importance of Gender. Int J Soc Psychiatry. May 8;20764020927051.

• 3. Clinical Challenge: Chronic Pain and COVID-19 — Pain patients may be hit harder

than others

Pain is Complex in Women

• Takes years to get the right

diagnosis and access the right treatment.

• Proper treatment regimen

is complicated.

• Higher levels of pain and

emotional distress as well as less function with PTSD.

• Use opioids at higher doses

and for longer periods.

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Women have greater and higher risk of pain conditions and related comorbidities

Maixner, W, Fillingim, RB, et al. (2016). Overlapping Chronic Pain Conditions: Implications for Diagnosis and Classification. J Pain. Sep; 17(9 Suppl): T93–T107.

Chronic Pain Affects Daily Lives

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• 1004 Women Surveyed
• May 23-June 18, 2019
• Social media, newsletter and

partner outreach

Impact of Chronic Pain on Women

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2 or more painful conditions

95% Full and active life impacted 65% Need more trained providers 56% Need more resources 38% Lack access to enough information about pain 62% Hopeless/ helpless about pain ½ Unable to sleep

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https://www.healthywomen.org/chronic-pain-summit

Unique Summit Focused on Women’s Chronic Pain

Full Report Video Presentations Relevant Content

“It’s central to the unique issues women face in pain management to understand the differences between men and women with respect to pain sensitivity, response to pain medication and predisposition to clinical pain conditions”

• Draft Report on Pain Management Best Practices: Updates, Gaps,

Inconsistencies and Recommendations. U.S. Department of Health and Human Services

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Treatment & Management of Chronic Pain

• Individualized patient-centered care with

multidisciplinary approach using one or more treatment modalities.

• Incorporate biopsychosocial model of care
• Compassionate empathetic care to overcome stigma
• Improving education for patients, families, caregivers,

clinicians, and policymakers

• Addressing existing barriers to care
• Continued medical and scientific research for new and

effective diagnostic, preventive and therapeutic approaches for patients

U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Retrieved from U. S. Department of Health and Human Services website: https://www.hhs.gov/ash/advisory- committees/pain/reports/index.html

Barriers to Treatment and Management of Chronic Pain to Women

• Unique biological barriers and

challenges

• Differential response to opioids &

nonpharmacological approaches.

• More likely to have depression with

pain.

• High rates of interpersonal trauma,

with PTSD associated with higher pain intensity, greater disability and greater emotional distress.

• Subject to stigma from friends,

family and medical establishment (“the pain is in your head”).

• Less likely to be queried about pain

at medical appointments.

• Undertreatment and discounting

experience due to overemphasis on the biological cause of pain.

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Biopsychosoc ial model of Care

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Barriers Unique to Women of Color

Physical barriers

Adequate supplies of opioids in low-income white neighborhoods compared to minority high-income neighborhoods.1

Physician attitudes

Racial and ethnic stereotyping or Implicit/Unconscious bias Discount pain in minority women who report high levels of pain.2

Patient factors

Patients’ perceptions of pain can differ among racial and ethnic populations. Socioeconomic status, pain reporting, pain behavior and mistrust

• f medicine.2

“The unequal burden and the unheard voices of women, particularly women

• f color, are, I believe, one of the most

pressing needs in pain research.” – Carmen Green, MD, Professor, Anesthesiology, Obstetrics and Gynecology, and Health Management and Policy, University of Michigan

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Patients

Addressing Biopsychosocial Barriers

Validate & Understand Interference of Pain Reflect, Assess, Factors, Future Communicate with Providers Share your answers with providers and ask for treatment recommendations that address goals. Understand Treatment and management may require interventions at the biological, psychological and social level.

Providers

Validate & Address the Burden of Pain Empathize, Assess, Reflect, Connect Improve Communication Be transparent about treatment decisions especially when expectations are at odds with treatment guidelines Practice Trauma-Informed Care Assume every person with pain may have a history of prior trauma and act accordingly Sensitively Address Mental Health Normalize overlap between pain and mental health “It’s not all in their head. . .”

“Its amazing women get care at all.” – Mary Driscoll, PhD, Clinical Research Psychologist, Yale School of Medicine; PRIME Center, VA Connecticut Healthcare System, VA Women’s Health Services

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Impact of COVID-19 on Treatment and Management of Chronic Pain

• Limited healthcare visits and temporary suspension
• f interventional & in-pain therapies have

disrupted care.1

• Chronic opioid therapy and steroids use may cause

immunosuppression.2

• Patients with COVID-19 receiving opioids can be

more susceptible to respiratory depression.2

77.4%

Facing barriers to medical care 10.2%

Clinician refused to fill medication via telehealth

• 1. Deer, T. et al. (2020). Emergence From the Coronavirus Disease 2019 Pandemic and the Care of Chronic

Pain: Guidance for the Interventionalist. Anesth Analg. 2020 May 26 : 10.1213/ANE.0000000000005000.

• 2. Recommendations on Chronic Pain Practice during the COVID-19 Pandemic: A Joint Statement by

American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA)

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Better Health Outcomes for Chronic Pain Patients

34.1%

Concerned with contracting COVID-19

31.6%

Need resources on "help with handling added stress and anxiety"

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Healthy Women Resources

Chronic Pain

• Chronic Pain for Women Is Real
• Bias, Chronic Pain and Access to Care — Health Care Provider's Perspective
• Resilience and Other Tools for Overcoming Barriers to Care for Women With Chronic Pain — Patient's Perspective
• I've Lived With Chronic Migraine Since Childhood
• A Call to Action for Helping Women in Chronic Pain

Mental Health

• Depression in the Time of Coronavirus
• How I’m Embracing the Shape-shifting Nature of Grief
• As It Stands: The Black Woman Still Reigns in Spite of the Rain
• Live with HealthyWomen: Mental Wellness & COVID-19

COVID-19

• 7 Ways to Take Control of Your Mental & Physical Health During COVID-19
• Don't Postpone These Types of Preventive Care Due to Coronavirus
• Grieving is Hard, Necessary Work and Coronavirus Makes it Harder
• Coronavirus Is Killing More Men Than Women — Why That Matters
• Why Women Are Needed in COVID-19 Clinical Trials

HealthyWomen.org/ChronicPainBarriers

Thank you

Monica Mallampalli, PhD monica@healthywomen.org Follow HealthyWomen! Facebook |Twitter | Instagram | Pinterest | LinkedIn

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Reducing Patient Risk at the Intersection of Mental Health and Chronic Pain in the Era of Precision Medicine

Gretchen Clark Wartman National Minority Quality Forum

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About the National Minority Quality Forum

The National Minority Quality Forum, a 501(c)(3) not-for-profit research and advocacy organization based in Washington, DC founded more than 20 years ago by Gary A. Puckrein, PhD in response to system inequities.

• The mission of the Forum is to reduce patient risk by assuring
• ptimal care for all.
• The Forum’s vision is an American health services research,

delivery and financing system whose operating principle is to reduce patient risk for amenable morbidity and mortality while improving quality of life.

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About the National Minority Quality Forum

NMQF is:

• Non-partisan
• Disease agnostic
• Population-centric

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About the National Minority Quality Forum

NMQF’s Capabilities:

• Data Collection and Analysis
• Geo-Mapping and Publication of Therapeutic Area Indexes
• Policy Analysis, Education and Advocacy
• Issue-Specific Alliance Development and Engagement
• Community-Based Provider Quality Improvement Initiatives

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About the National Minority Quality Forum

NMQF’s Priorities:

• Research designs that assure the statistically-significant

inclusion of population cohorts that are under-represented in clinical trials and research.

• The identification and elimination of clinical guidelines,

formulary management tools, performance measures and payment models that may serve to create, reinforce or codify inequities in access to health services.

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About the National Minority Quality Forum

NMQF’s Priorities (continued):

• Diagnosis and treatment guidelines and prescription drug

formularies that reflect safety and efficacy, and provide clinicians with maximum flexibility in responding to patient needs and preferences.

• The collection, analysis and publication of data that identify

and monitor diagnosis and treatment inequities in geographic areas and patient/beneficiary cohorts.

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About the National Minority Quality Forum

NMQF’s Priorities (continued):

• Diagnosis and treatment guidelines and prescription drug

formularies that reflect safety and efficacy, and provide clinicians with maximum flexibility is responding to patient needs and preferences.

• The collection, analysis and publication of data that identify

and monitor diagnosis and treatment inequities in geographic areas and patient/beneficiary cohorts.

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Therefore, perhaps most important is the fact that recent events have highlighted population- specific inequities and system-wide inadequacies in a manner that increases the potential to harness political and economic will to effectuate sustainable change.

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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Related NMQF Initiatives

• Thought Leaders Conference on Mental Health in Minority Communities in November 2003 (Sponsor)
• Neuropsychiatric Symptoms Working Group (Sponsor)
• ICD-CM Coding for Dementia
• Brain Health in Long-Term Care Alliance (Sponsor)
• Protecting Access to Pain Relief Coalition (Member)
• Development of a performance e-measure for the treatment of heart failure in African-Americans.

(Sponsor)

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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Constructive engagement with the mental health and pain management quality improvement challenge will require all stakeholder sectors to operationalize every objective or value regarding inclusion, diversity, quality improvement, and patient engagement that they publicly embrace. Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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Therefore, we offer the following comments and recommendations:

• Put processes in place that define quality outside of the

context of money.

• Remember - populations are marginalized by external

factors that human beings control.

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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Recommendations (cont.):

• Seek and create partnerships. Be proactive in finding ways

to collaborate in a pre-competitive or non-competitive space.

• Recognize and constructively engage the political and

economic levers of change.

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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Recommendations (cont):

• Evaluate all value constructs, performance measures, and quality

measures through a patient risk reduction lens, both the development processes and their impact on patient outcomes.

• Find incentives to influence payer policy and provider behavior

that don’t put patients at risk for poor outcomes – financial or health.

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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How can NMQF help?

• Build an alliance of stakeholders in mental health and pain

management (patient advocacy organizations, provider associations, industry) to develop a strategic, evidence-based approach to improve patient outcomes.

• Co-author studies for publication in peer-reviewed journals.
• Collaborate with MHA and its stakeholders to produce a geo-map

index to support and monitor efforts to improve outcomes of care.

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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NMQF data analyses and geo-maps that:

• Provide demographic intelligence about acute and chronic mental disorders at

the zip code level based upon administrative claims data for mental and physical health disorders and prescription drug data – tabulated by age, sex, race, ethnicity.

• Map prevalence, cost, outcomes, comorbidities, socioeconomic status or other

data type for any state, MSA, and congressional and state legislative districts.

• Enable monitoring of defined metrics to document patient experience and
• utcomes of care; forecasting of trends using predictive analytics; and

production of customized reports to support policy, advocacy, and quality improvement initiatives at the federal, state and local levels.

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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The Medicare Heart Failure Market

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The Medicare Heart Failure Chicago

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Medicare African Americans with HF in Zip Code 60612

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In 2011, there were 484 African Americans Medicare Beneficiaries with HF.

Sample Physician Profile

This physician’s HF Patients:

• Had 1,534 hospitalizations
• A hospitalization rate of 3.2 per Patient
• An All Cause reimbursements of $41,328,548
• An Annual Per Patient All Cause Cost $85,389
• All Cause Hospitalizations reimbursements of $23,216,302
• Annual Per Patient Hospital Cost $47,967
• 391 (80%) of his HF Patients had 560 Hospital Readmissions
• A Mortality Rate of 26% (N=127)
• 374 (77%) of His HF Patients had 1,166 ER Visits

Internal Medicine Specialist A Medical Center Southeastern Michigan 48075-4318

This Photo by Unknown Author is licensed under CC BY-ND

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Possible analysis and index:

• Mental health-related related ICD and

procedure codes

• Physical health-related ICD and procedure

codes

• Anonymized patient data
• Prescription drug data
• Physician-specific data

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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“In economics, things take longer to happen than you think they will, and then they happen faster than you thought they could.” Rüdiger "Rudi" Dornbusch Economist

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

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Thank you! Gretchen Clark Wartman Vice President for Policy and Program National Minority Quality Forum gwartman@nmqf.org

Reducing Patient Risk at the Intersection of Mental Health Treatment and Pain Management

Questions and Answers

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